OMB No. 1545-2246
Form  8966                                                                FATCA Report

Department of the Treasury         ▶
Internal Revenue Service             Go to www.irs.gov/Form8966 for instructions and the latest information.                                    2021
If you are filing paper Forms 8966, enter the three-digit identifier number used to identify this Form 8966 filing 
(see instructions)  .    .  . . .  . . .             . .  . . .           . . . .     . . . .    . . . .         . . .      .        . . .   .  ▶
Check if report is being corrected, amended, voided, or there are no accounts to report:
   Corrected report                Amended report                         Voided report        Check if no accounts to report (see instructions)
Part I       Identification of Filer
1a  Name of filer                                                                     1b Enter the filer category (see instructions) ▶

2    Number, street, and room or suite no. (if P.O. box, see instructions)

3a  City or town                                     3b    State, province, or region                3c   Country, including postal code 

4   Global intermediary identification number (GIIN)                                    5   TIN
                            .                          .                .
6  Name of sponsored entity or intermediary, if applicable

7   Number, street, and room or suite no. (if P.O. box, see instructions)

8a  City or town                                     8b   State, province, or region                 8c   Country, including postal code 

9   GIIN                                                                                10  TIN
                            .                          .                .
Part II      Account Holder or Payee Information
1a Name of account holder or payee                                                                   1b Indicate whether account holder or payee is an individual or entity
                                                                                                         Individual                    Entity
2  Number, street, and room or suite no. (if P.O. box, see instructions)

3a  City or town                                     3b   State, province, or region                 3c   Country, including postal code 

4  TIN

5  If account holder or payee is an entity, check applicable box to specify the entity type:
   Owner-Documented FFI with specified U.S. Owner(s)                                        Passive NFFE with substantial U.S. Owner(s)
   Non-Participating FFI                                                                    Specified U.S. Person
Part III     Owner Information (File a separate report for each U.S. Owner that is a specified U.S. Person.)
1  Name of owner

2  Number, street, and room or suite no. (if P.O. box, see instructions)

3a  City or town                                     3b   State, province, or region                 3c   Country, including postal code 

4   TIN of owner

Part IV       Financial Information
1  Account number                                                                       2   Currency code (see instructions)

3a  Account balance
                                                                                        3b  Check if account closed during the year (see instructions)
4a  Interest                                                                            4c  Gross proceeds/Redemptions

4b  Dividends                                                                           4d  Other

For Paperwork Reduction Act Notice, see separate instructions.                                   Cat. No. 55748F                                 Form 8966 (2021) 

Form 8966 (2021)                                                                                                        Page 2 
Part V Pooled Reporting Type
1   Check applicable pooled reporting type (check only one):
    Recalcitrant account holders with U.S. Indicia              Recalcitrant account holders without U.S. Indicia
    Dormant accounts                                            Non-Participating FFI
    Recalcitrant account holders that are U.S. Persons          Recalcitrant account holders that are passive NFFEs
2   Number of accounts                                      3   Aggregate payment amount
4   Aggregate account balance                               5   Currency code

                                                                                                                   Form 8966 (2021)